A 25-year-old man comes to the emergency department with difficulty swallowing. He has had a piece of steak stuck substernally for the past 12 hours. The patient has failed to dislodge it despite inducing himself to vomit. He has never had trouble swallowing liquids or solids previously, although he has had frequent heartburn for the past few years and has tried lansoprazole without improvement. He had bronchial asthma since childhood for which he takes inhalers. Temperature is 37.1 C (98.8 F), blood pressure is 136/79, pulse is 85/min, respirations are 12/min. Cardiopulmonary and abdominal examinations are unremarkable. Skin examination is unremarkable. When presented with a glass of water, he vomits the water seconds after swallowing but the piece of steak remains stuck. An urgent endoscopy is arranged to be performed in the emergency department. Which of the following is the most likely explanation for this presentation?

Question

A 25-year-old man comes to the emergency department with difficulty swallowing.  He has had a piece of steak stuck substernally for the past 12 hours.  The patient has failed to dislodge it despite inducing himself to vomit.  He has never had trouble swallowing liquids or solids previously, although he has had frequent heartburn for the past few years and has tried lansoprazole without improvement.  He had bronchial asthma since childhood for which he takes inhalers.  Temperature is 37.1 C (98.8 F), blood pressure is 136/79, pulse is 85/min, respirations are 12/min.  Cardiopulmonary and abdominal examinations are unremarkable.  Skin examination is unremarkable.  When presented with a glass of water, he vomits the water seconds after swallowing but the piece of steak remains stuck.  An urgent endoscopy is arranged to be performed in the emergency department.  Which of the following is the most likely explanation for this presentation?

Quizplus · Accepted Answer

11ec25c8_d312_6e61_bc81_9d2a48647467_MD0003_00 This patient has an esophageal food impaction, which most commonly occurs when food becomes trapped in the esophagus due to a preexisting abnormality (eg, ring, stricture). Drooling, hypersalivation, and an inability to tolerate liquids (eg, vomiting after drinking water) are cardinal symptoms. Food impaction can lead to esophageal perforation and requires urgent upper endoscopy with food bolus removal. Although any physiologic or pathologic esophageal narrowing can predispose to food impaction, several features of this patient's presentation suggest that eosinophilic esophagitis (EoE) is the most likely underlying etiology. EoE commonly affects young men (age 20-30) and is frequently associated with other atopic conditions (eg, seasonal allergies, eczema, asthma). In addition to refractory heartburn despite a proton pump inhibitor (as seen in this patient), other common manifestations include intermittent solid food dysphagia and substernal chest or upper abdominal pain. More than 50% of patients have a history of food impaction, which typically occurs when progressive esophageal inflammation from untreated EoE leads to stricture formation. The diagnosis of EoE is confirmed with esophageal biopsies demonstrating eosinophilic mucosal infiltration (eg, ≥15 eosinophils/hpf). If diagnosed early, EoE responds well to an elimination diet or topical glucocorticoids (eg, fluticasone, budesonide); stricture dilation may be required if there is no response to medical therapy. (Choice A) Disordered oropharyngeal neuromuscular transmission can occur in amyotrophic lateral sclerosis and multiple sclerosis. However, these disorders typically present with symptoms of oropharyngeal dysphagia (eg, coughing after eating, nasal regurgitation, aspiration) rather than esophageal food impaction. (Choice C) Achalasia results from myenteric plexus degeneration, which causes incomplete relaxation of the lower esophageal sphincter. Patients with achalasia tend to present with progressively worsening dysphagia (solids and liquids), not a sudden food impaction. (Choice D) Fibrosis and atrophy of esophageal smooth muscle occurs in systemic sclerosis; this leads to chronic, often severe gastroesophageal reflux and may result in strictures with food impaction. However, systemic sclerosis is expected to affect multiple organ systems; cutaneous (eg, skin thickening) and extracutaneous (eg, Raynaud phenomenon) findings would be expected. (Choice E) Esophageal cancer can rarely cause food impaction, but it tends to affect elderly patients and presents with progressive dysphagia (from solids to liquids) and weight loss. Educational objective: Eosinophilic esophagitis commonly affects young men and is frequently associated with other atopic disorders. It can present with intermittent solid food dysphagia and refractory heartburn. More than 50% of patients have a history of food impaction. The diagnosis is confirmed with biopsies demonstrating eosinophilic infiltration of the esophageal mucosa. References: ACG clinical guideline: evidenced based approach to the diagnosis and management of esophageal eosinophilia and eosinophilic esophagitis (EoE). (http://www.ncbi.nlm.nih.gov/pubmed/23567357) Diagnosis and treatment of eosinophilic esophagitis in clinical practice. (http://www.ncbi.nlm.nih.gov/pubmed/28247277)

A 25-Year-Old Man Comes to the Emergency Department with Difficulty